Symptom: Dizziness

Initial Grading Reminder

CTCAE Grading of Dizziness:

Grade 1: Mild unsteadiness or sensation of movement
Grade 2: Moderate unsteadiness or sensation of movement; limiting instrumental ADLs
Grade 3: Severe unsteadiness or sensation of movement; limiting self-care ADLs

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Do you have any history of GI problems? Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly? Have you recently started any new medications, OTCs, supplements, or marijuana? Does anyone in your household have diarrhea/vomiting?

Grade the symptom

Ask the patient:

How frequently are your bowel movements? How much have they increased over your normal? Are you having accidents? Are you feeling faint? Are you able to keep water down? Are you urinating?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you have any rash, are you feeling flush, or having difficulty breathing? Did you have any difficulty with your infusions? Do you have any back pain, itching, flushing, difficulty breathing? Do you have a fever?

Note: These symptoms are suggestive of an allergic reaction.

Are you drinking (how much fluid are you drinking per day)? Do you have diarrhea? Do you have a stiff neck or headache? Do you have any swelling in your legs? Have you had any seizures or hallucinations? Is your breath fruity? Have you been urinating (a little or a lot)? Do you have any severe abdominal pain?

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

  • Click Here for Telephone Triage

    Suggested Intervention

    Any patient with moderate or worse (or worsening) unsteadiness should be seen.

    Patients with any of the red-flag symptoms should be seen immediately.

    Patients with any of the signs of an allergic reaction should go right to the ED.

  • Click Here for In-Office Triage

    Nursing Assessment of Potential Causes

    Hypophysitis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear fatigued?
    • Does the patient look listless?
    • Does the patient look ill?
    • Does the patient look uncomfortable?
    • Does the patient report:
      • Change in energy?
      • Headache?
      • Dizziness?
      • Nausea/vomiting?
      • Altered mental status?
      • Visual disturbances?
      • Fever?
    • Low levels of hormones produced by pituitary gland (ACTH, TSH, FSH, LH, GH, prolactin)
    • Brain MRI with pituitary cuts: enhancement and swelling of the pituitary gland
    • DDX adrenal insufficiency: low cortisol and high ACTH
    • DDX primary hypothyroidism: low free T4 and high TSH

    GI Toxicity - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear weak?
    • Has the patient lost weight?
    • Does the patient appear dehydrated?
    • Does the patient appear in distress?
    • Quantity & quality of bowel movements (e.g., change in/increased frequency over baseline): solid, soft, or liquid diarrhea; dark or bloody stools; or stools that float
    • Fever
    • Abdominal pain or cramping
    • Increased fatigue
    • Upset stomach, nausea, or vomiting
    • Bloating/increased gas
    • Decreased appetite or food aversions
    • Serum chemistry/hematology abnormalities
    • Infectious vs immune-related adverse event causation
    • Peritoneal signs of bowel perforation (i.e., pain, tenderness, bloating)

    Encephalopathy - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient look uncomfortable?
    • Does the patient look ill?
    • Does the patient report headache, fever, tiredness, sleepiness, hallucinations, stiff neck?
    • Signs of infectious cause (lumbar puncture); Obtain brain MRI; Consult neurologist

    Type 1 Diabetes Mellitus - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear fatigued?
    • Does the patient appear dehydrated?
    • Does the breath have a sweet/fruity smell?
    • Is the patient tachycardic?
    • Frequent urination?
    • Increased thirst?
    • Increased hunger?
    • Increased fatigue?
    • Altered level of consciousness with advanced cases
    • Symptoms of diabetes
    • Serum glucose levels
    • Other immune-related toxicity
    • Infections

    Cardiotoxicity - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient look unwell?
    • Fatigued?
    • Diaphoretic?
    • SOB or in respiratory distress?
    • Is there leg edema?
    • Change in energy level?
    • SOB or DOE?
    • Leg edema?
    • Palpitations?
    • Changes in BP?
    • Dizziness or syncope?
    • What exacerbates or improves symptoms?
    • Any new prescribed or OTC meds? Illicit substances?
    • Any underlying cardiac disease (CAD, MI, or other)?
    • What exacerbates or improves symptoms?
    • Prior radiation therapy?
    • Determine specific toxicity and related grade (if applicable)
    • Other related symptoms: hypotension, syncope, chest pain, DOE, SOB, palpitations, edema, etc.
    • Impact of symptoms on QOL/performance status
    • Changes in cardiac function: ECG changes, decreased EF, elevated cardiac enzymes (troponin, CK)
    • Assess other changes in oxygen saturation, BP, lung function

    Allergic Reaction to Infusion

    Rash, flush, breathing difficulty, back pain, itch, fever, confusion, dizziness

    Differential Diagnosis

    What do you suspect is the cause of the dizziness?